KINDEST CUT OF ALL

World's first ever penile transplant

Leadership sat down with Professor Andre van der Merwe, the man who led the team of surgeons who performed the world’s first penis transplant, and head of Stellenbosch University’s Division of Urology.

On 11 December last year, Tygerberg Hospital, nestled in the leafy northern Suburbs of Cape Town, placed itself firmly and squarely on the world map when, behind its somewhat monolithic facade, surgeons performed one of the most incredible operations in history—the world’s first penile transplant—another staggering milestone for South African medical science.

The man who this groundbreaking surgery was performed on (who wishes to remain anonymous) was yet another in a long line of young men who are victims of botched circumcision, but at the age of 21 he was given back his dignity, not to say his manhood, and at the same time gave hope to thousands who have suffered a similar fate.

Every year in South Africa roughly 250 young men have to undergo penile amputations, mostly due to botched circumcisions, but also from penis cancer, birth defects and other diseases.

Van der Merwe explains that at present the procedure affects only victims of “ritual circumcision,” but he adds that people with “born defects or a disease called Epispadias will also definitely be able to be helped” in the near future.

The project was not without its problems —and as with any “firsts” there were many sceptics, much criticism, and perhaps jealousy in some quarters. Van der Merwe says he has been called mad many times, “but my critics have made me work harder to achieve this.”

“Not lifesaving”

He says males were generally supportive, but he encountered a lot of resistance from females, specifically white females. The biggest argument was that the surgery is not lifesaving, but rather cosmetic, so a patient could undergo psychological counselling and be fine at the end of it. On a more extreme level, he had to deal with the sort of view that maintained that the earth had more than enough people already, “so why should we make someone fertile again”?

Van der Merwe believes the latter argument is not only “completely unethical” but also downright absurd “because people are trying to put their own global population perspectives onto one individual”.

However, Van der Merwe says he also had a lot of support, especially from those at Tygerberg Hospital. While some medical practitioners were saying it was an unnecessary operation, and others that it simply wouldn’t work, Van der Merwe, along with his team, pushed through and overcame these obstacles.

It is not the first time that Van der Merwe has faced criticism for a pioneering project. Behind the surgical gloves and scrubs is a man with farming in his heart and who runs the family farm—with the help of a neighbour—deep in the Karoo in the star gazing capital of the country, Sutherland, where he also grew up.

But even this has not been without its challenges. Sheep farming is the bread and butter of the Karoo, but as Van der Merwe explains, “it is not very lucrative at the moment, unless you have a really large piece of land.” So he has now started a “champagne-type winery project” which has faced a lot of resistance from people who say it won’t work. However, Van der Merwe is hopeful that it will enhance the economy of the region. “We have done all the testing, and while some obstacles exist, I’m confident we can overcome them.”

While one would not generally associate farming and surgery, Van der Merwe says that farming helped prepare him tremendously for the world’s first penile transplant, especially from a planning perspective. “With farming there is a lot of planning, and while my neighbour runs it when I’m not there, I am still involved in all the planning, which has taught me how to plan effectively.”

The penile transplant project began in 2010, and Van der Merwe says he realised early on that it would be ethics that would make or break the initiative, so he called a meeting with all the relevant managers at Tygerberg Hospital in 2011 to give an ‘ethics talk’. At the time funding was extremely hard to come by as many felt it would be too risky to invest.

After the ethics talk Tygerberg Hospital’s management bought into the idea and that is how the finance was eventually obtained. “It fell under clinical incident, so all the extra money came from the transplant budget at Tygerberg Hospital,” van der Merwe explains.

“Often in government hospitals one finds a lot of tension between physicians and management, but fortunately there is no such thing at Tygerberg, which set a good platform for us to go ahead with the project. Management at Tygerberg should also get a lot of credit because as we faced criticism, this just enhanced their support for us,” he says.

More good news

Recently, more good news broke when it was confirmed that the patient who received the penile transplant had impregnated his long-standing girlfriend. While this has surprised many—occurring as it did so soon after the operation—Van der Merwe is not taken-aback at all.

“There is no reason why he shouldn’t be fertile. Everything was normal; he still had the same sensation, his testicles were fine—and now he has a penis. It doesn’t surprise me at all that he has impregnated his girlfriend.”

But as usual, the sceptics still don’t go away. Many have asked the question how anyone could know whether or not it is the patient’s child, but Van der Merwe says he hasn’t, and will not at any stage do a paternity test.

While he says he is aware that “things can happen and you never really know”, he has no reason to doubt because the patient has no reason not to be fertile.

Other than the standard criticism from some quarters, as well as obtaining funding, the project had numerous other challenges to overcome between its inception in 2010 and the operation on 11 December 2014. Because a penile transplant had never successfully been completed, a lot of research needed to be done.

According to Van der Merwe, he undertook much research and reading about face and hand transplants as there are analogies between this and the type of surgery undertaken by himself and his team, and in 2012 the team did the first test transplant with cadavers. They learnt a lot of lessons from this and were basically “ready with the project”, but yet another obstacle landed in their path—finding a suitable donor.

Van der Merwe says at this point he took a break from the project as he didn’t believe his own skills were good enough to complete it at this stage. Instead, he did an MSc Clinical Epidemiology Degree, which was to enhance his research skills.

“I needed to improve my quantitative research skills so that I could do depth interviews to really get to the bottom of the problem with small numbers of people—you know we are not really dealing in massive patient numbers, so we get a lot from these depth interviews. When it comes to large patient groups one can use statistics and analyse the entire group.”

One day, while on an evening jog, Van der Merwe found his answer. People were not willing to let their loved ones go to the grave without a penis, as they felt it took away their dignity. So with the assistance of some plastic surgeons, they came up with a suitable replacement for the donor to create something that closely resembles a penis.

They decided to approach families with brain-dead members and spoke to them about their loved onces becoming donors. Suddenly Van der Merwe found that families were starting to think about it rather than just dismissing the idea.

On the day he got his Masters degree in MSc Clinical Epidemiology, he also got the call that a donor had been found. A nine hour operation followed.

“There is always a chance that the body will reject the penis, but the longer it takes, the smaller the chance of that happening—this is why I am so happy that he will now be a father. You know, in his culture it is important to be able to have kids.”

Failed attempt

While this was the first successful penis transplant, there has been a failed attempt—in China. In that case, the Guangzhou General Hospital hosted the surgery, but two weeks after the transplant, the penis needed to be removed after problems arose.

“There was also a centre that did a mouse study—they transplanted a penis from one to the other, which helped me a lot because that meant I didn’t have to go that route again as I believe it is unethical to repeat the study.”

Van der Merwe explains that this is not just a case of someone needing a penis, finding a suitable donor, and then doing the procedure. Bar the research that needs to be done, and the extensive testing, the patient needs to go through quite a lenghty psychological test period.

“We currently have 11 people who have been evaluated about needing this, and nine are ready to be transplanted. However, it is a long process. I’d say it takes between 6-12 months for all the blood tests, psychological evaluation and to just see how they react to the programme.”

Depression and psychosis

He adds that they monitor the patients on follow-ups to see how they behave because they cannot put anyone into the programme with any sort of psychological instability, or if they suffer from depression or psychosis. The problem is that it is a “very expensive and time consuming procedure”, and if there is any risk that the penis will reject a patient because they haven’t taken their medication, “the risk is unacceptable”.

This historic procedure has yet to win him, or his team members, any awards, but their feat has been featured on some of the largest news networks in the world, including the BBC and CNN. Congratulations from all over the globe have poured in, and show no sign of abating any time soon. South African medical science has received a lot of flack in recent years, but Van der Merwe believes some people have the wrong impression. Tygerberg Hospital and Stellenbosch University’s Faculty of Medicine and Health Sciences are at the forefront of vital research, as their relationship continues to blossom with yet another medical first.

“People think we are not where we should be in terms of training, but we are at the forefront in terms of HIV and TB. There is no point doing research on diseases that are only prevalent in the US, for example. We have to focus on what we have in South Africa, and maybe, like with this project, the world will want to know how and what we did.”

Some people will continue to find fault with this project, despite the fact that an individual was given a new chance in life, and many others given hope, but for the good professor, it only matters that it can be done, and those who criticise “will only make me more determined”.

Van der Merwe says his three children are probably proudest of him. “They take the newspaper articles and video clips and sort of beam.”

What the future holds is unknown, and because this procedure is life-changing, as opposed to lifesaving, preventative measures are far better than a full transplant. Unfortunately, however, with the number of traditional circumcisions happening on a daily basis, one fears many more young men will suffer a similar fate in the months and years to come as that experienced by Tygerberg’s pioneering patient. Now, though, thanks to Prof. van der Merwe and his team, there is hope.